The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative evaluation for extent of disease, and
role of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aim
of the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant
Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.
The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.
Symptoms and Signs
- Early-stage disease
- Asymptomatic--abnormal chest x-ray
- Intrabronchial symptoms--cough, hemoptysis, wheeze, stridor, recurrent
pneumonia, shortness of breath
- Paraneoplastic syndromes (eg, clubbing)
- Advanced-stage disease
- Locally advanced--hoarseness, hiccups, chest pain, Pancoast syndrome,
superior vena cava syndrome
- Distant metastases--neurologic symptoms/signs, bone pain, weight loss,
Evaluation of the Symptomatic Patient
- Chest x-ray
- CT scan
- Cytologic or histologic confirmation
- Sputum cytology
- Bronchoscopy--cytologic washings, brushings, biopsy, needle aspiration
- Transthoracic needle aspiration biopsy
- Mediastinoscopy or mediastinotomy
- Thoracoscopy or thoracotomy
- Timeliness--evaluation of all patients with persistent (few
weeks) symptoms suggestive of distant metastases
Preoperative Evaluation for Extent of Disease
- Complete history and physical examination
- Rule out local invasive manifestations and distant metastases (systemic
- Evaluate all symptoms suggestive of metastatic disease.
- Chest x-ray
- CT scan
- Chest and upper abdomen to include adrenal glands
- Further studies
- Depend on determination from above of locally advanced disease or suspected
- Mediastinoscopy and/or mediastinotomy
- Bone scan
- CT scan of head (MRI if indicated)
- Percutaneous needle biopsy--for suspected metastases discovered on
imaging (eg, pleura, lung, liver, adrenal gland, bone)
Role of Surgeon in Management
- The surgeon may be responsible for all preoperative assessment, including
diagnostic and extent of disease work-ups and cardiopulmonary assessments.
- Diagnostic procedures
- The surgeon must be totally adept at performing bronchoscopy (rigid
and flexible), mediastinoscopy, mediastinotomy, and thoracoscopy, and is
responsible for clinically staging the tumor.
- Surgical considerations
- Curative resection, ie, complete excision of tumor. Intentional palliative
(incomplete) resections are not commonly indicated. Patients shown to have
mediastinal lymph node disease, if consid- ered for ultimate surgical therapy,
are usually placed on preoperative induction chemotherapy or chemoradiotherapy
- Surgeon must be adept at all techniques of pulmonary resection and
extended resections, including wedge resection, segmental resection, lobectomy,
pneumonectomy, sleeve resections, en bloc chest wall resection, etc. The
surgeon should be able to perform mediastinal lymph node dissections and
more complex resections, eg, resections for superior sulcus tumors, sleeve
pneumonectomies, and vascular sleeve resections.
These guidelines are copyrighted by the Society of Surgical Oncology
(SSO). All rights reserved. These guidelines may not be reproduced in any
form without the express written permission of SSO. Requests for reprints
should be sent to: James R. Slawny, Executive Director, Society of Surgical
Oncology, 85 W Algonquin Road, Arlington Heights, IL 60005.
Lung cancer is the most common cause of cancer death for both men and
women in North America. The age-adjusted incidence is 60 cases per 100,000
people, but by age 70 in males incidence exceeds 500 cases per 100,000.
Cigarette smoking has been firmly implicated as the primary cause of
this cancer. Other environmental pollutants that have been implicated include
passive smoking, radon exposure, and occupational exposure to polycyclic
aromatic hydrocarbons, nickel, uranium, and asbestos. Most of these occupational
factors act as cocarcinogens with smoking. There is a proven familial incidence
of this disease.
Despite the well-known etiologic factors, attempts at mass screening
of high-risk individuals using annual sputum cytology and chest x-ray have
failed to improve ultimate survival from lung cancer, although early cases
can be detected by such screening.
American Joint Committee: Manual for Staging of Cancer, 4th ed. Chicago,
American Joint Committee on Cancer, 1992.
Dillman RO, Seagren SL, Propert KJ, et al: A randomized trial of induction
chemo plus high- dose radiation versus radiation alone in stage III non-small
cell lung cancer. N Engl J Med 323(14):940-945, 1990.
Eddy DM: Screening for lung cancer. Ann Intern Med 111:232-237, 1989.
Flehinger BJ, Kimmel M, Melamed MR: The effect of surgical treatment
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Roth JA, Fossella F, Komaki R, et al: A randomized trial comparing perioperative
chemotherapy and surgery with surgery alone in resectable stage IIIa non-small
cell lung cancer. J Nat Cancer Inst 86:673-680, 1994
Shepherd FA, Ginsberg RJ, Patterson GA, et al for The University of
Toronto Lung Oncology Group: A prospective study of adjuvant surgical resection
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